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In Reply:-Dr. Viby-Mogensen makes an important point, namely, that all significant complications do not occur immediately postoperatively. The paper to which he refers clearly documents the fact that inadequate neuromuscular blockade can occur. However, the doses of neostigmine given to patients in his pancuronium group, or the time interval after the last pancuronium dose, may have been insufficient. The authors documented this by noting that patients often arrived in the PACU with low train-of-four ratios. We believe that it is the adequacy of reversal, not the use of pancuronium per se, which influences the clinical outcome in the PACU and beyond.

The practice guidelines we proposed regarding the use of pancuronium are sound as long as enough medication is administered to achieve appropriate reversal. Reversal should be monitored by standard train-of-four monitoring, making sure a twitch is present before reversal, and one should assess the ability to sustain tetanus for 5 s in addition to having 4/4 twitches of near equal magnitude (> 0.7 T4/T1).